Pseudopolyps in inflammatory bowel diseases: Have we learned enough?

Sonographic detection of massive colonic pseudopolyposis in inflammatory bowel diseases

PURPOSE

Colonic pseudopolyps are a frequent finding in inflammatory bowel disease (IBD). Yet there are no published data describing the characteristics of pseudopolyposis in intestinal ultrasound (IUS). This study aimed at identifying the key features of pseudopolyposis in IUS.

METHODS

This case-control study included 12 patients with ulcerative colitis or Crohn's colitis with extensive left colon pseudopolyposis and 18 matched IBD patients without pseudopolyps at colonoscopy. Luminal (diameters, thickening, stratification, margins, and vascularity) and intraluminal (vascular signals at color Doppler), and extraluminal (mesenteric fat) parameters of the left colon were compared. Anonymized still images and videos of these patients were blindly reviewed to estimate the accuracy in detecting this condition.

RESULTS

Among the IUS parameters assessed, the anteroposterior diameter ≥ 12 mm and the presence of luminal vascular signals were significantly correlated with pseudopolyposis. The detection of both these findings were able to detect extensive pseudopolyposis a sensitivity of 75% (CI 95%: 42.8-94.5%) and a specificity of 100% (CI 95%: 81.5-100%).

CONCLUSION

This is the first study describing the IUS features of pseudopolyposis in IBD. The potential use of IUS to assess pseudopolyposis might have an impact on IUS monitoring and surveillance of IBD patients with condition.

Standardizing Scoring Conventions for Crohn's Disease Endoscopy: An International RAND/UCLA Appropriateness Study

BACKGROUND AND AIMS

Endoscopic assessment of disease activity is integral for evaluating treatment response in patients with Crohn's disease (CD). We aimed to define appropriate items for evaluating endoscopic activity and conventions for consistent endoscopic scoring rules in CD.

METHODS

A 2-round modified RAND/University of California at Los Angeles Appropriateness Method study was conducted. A panel of 15 gastroenterologists used a 9-point Likert scale to rate the appropriateness of statements pertaining to the Simple Endoscopic Score for CD, Crohn's Disease Endoscopic Index of Severity, and additional items relevant to endoscopy scoring in CD. Each statement was voted as appropriate, uncertain, or inappropriate based on the median panel rating and presence of disagreement.

RESULTS

Panelists voted that it is appropriate for all ulcers to contribute to endoscopic scoring in CD, including aphthous ulcers, ulcerations at a surgical anastomosis, and anal canal ulcers (scored in the rectum). Endoscopic healing should reflect an absence of ulcers. Narrowing should be defined as a clear decrease in luminal diameter; stenosis should be defined by an impassable narrowing, and if occurring at the junction of 2 segments, scored in the distal segment. Scarring and inflammatory polyps were considered inappropriate for including in the affected area score. The optimal method for defining ulcer depth remains uncertain.

CONCLUSIONS

We outlined scoring conventions for the Simple Endoscopic Score for CD and Crohn's Disease Endoscopic Index of Severity, noting that both scores have limitations. Therefore, we identified priorities for future research and steps for developing and validating a more representative endoscopic index in CD.

Obstructive Giant Inflammatory Polyp of the Colon in Ulcerative Colitis

Inflammatory polyps, also known as pseudo-polyps, are a common benign condition affecting 10-20% of patients with inflammatory bowel disease. Chronic, repeated inflammation and ulceration associated with healing lead to the formation of polyp-like structures in the colon. Although there are no common symptoms accompanying these pseudo-polyps, they can present with anemia, weight loss, diarrhea, intussusception, palpable mass, abdominal pain, discomfort, and melena, not to mention bowel obstruction that happens infrequently. Finally, it is important to recognize giant inflammatory polyps as they may occasionally be mistaken for colon cancer, leading to unnecessary surgical interventions. We present the case of a 38-year-old woman who was diagnosed with ulcerative colitis 10 years back, treated with oral mesalamine for five years, and had no follow-up after this period. She came to our clinic complaining of recurrent obstructive symptoms for a few months. Examination shows tenderness in the left lower quadrant with normal vital signs and bowel sounds.

Frequency and Predictors of Dysplasia in Pseudopolyp-like Colorectal Lesions in Patients with Long-Standing Inflammatory Bowel Disease

Current endoscopic surveillance programs do not consider inflammatory bowel disease (IBD)-associated post-inflammatory polyps (pseudopolyps) per se clinically relevant, even though their presence seems to increase the risk of colorectal cancer (CRC). However, it remains unclear whether the link between pseudopolyps and CRC is indirect or whether some subsets of pseudopolyp-like lesions might eventually undergo neoplastic transformation. This study aimed to assess the frequency and predictors of dysplasia in pseudopolyp-like lesions in a population with long-standing colonic IBD. This was a retrospective, single-center study including patients with a colonic IBD (median disease duration of 192 months) and at least a pseudopolyp-like lesion biopsied or resected in the period from April 2021 to November 2022. One hundred and five pseudopolyps were identified in 105 patients (80 with ulcerative colitis and 25 with Crohn's disease). Twenty-three out of 105 pseudopolyp samples (22%) had dysplastic foci, and half of the dysplastic lesions were hyperplastic. Multivariate analysis showed that the age of the patients (odds ratio (OR) 1.1; p = 0.0012), size (OR 1.39; p = 0.0005), and right colonic location (OR 5.32; p = 0.04) were independent predictors of dysplasia, while previous exposure to immunosuppressors/biologics and left colonic location of the lesions were inversely correlated to dysplasia (OR 0.11; p = 0.005, and OR 0.09; p = 0.0008, respectively). No differences were seen between ulcerative colitis and Crohn's disease patients. Lesions with a size greater than 5 mm had a sensitivity of 87% and a specificity of 63% to be dysplastic. These data show that one-fourth of pseudopolyp-like lesions evident during surveillance colonoscopy in patients with longstanding IBD bear dysplastic foci and suggest treating such lesions properly.

Repurposing of RAS-Pathway Mediated Drugs for Intestinal Inflammation Related Diseases for Treating SARS-CoV-2 Infection

Severe Acute Respiratory Syndrome coronavirus 2 (SARS-CoV-2) is an emerging zoonotic virus, which causes Coronavirus Disease 2019 (COVID-19). Entry of coronaviruses into the cell depends on binding of the viral spike (S) proteins to cellular receptors Angiotensin-converting enzyme 2 (ACE2). The virus-mediated reduction of ACE2/Ang1-7 causes flooding of inflammatory cytokines. A similar scenario of hyper immunologic reaction has been witnessed in the context of Intestinal Inflammatory Diseases (IIDs) with the deregulation of ACE2. This review summarizes several IIDs that lead to such susceptible conditions. It discusses suitable mechanisms of how ACE2, being a crucial regulator of the Renin-Angiotensin System (RAS) signaling pathway, can affect the physiology of intestine as well as lungs, the primary site of SARS-CoV-2 infection. ACE2, as a SARS-CoV-2 receptor, establishes a critical link between COVID-19 and IIDs. Intercessional studies targeting the RAS signaling pathway in patients may provide a novel strategy for addressing the COVID-19 crisis. Hence, the modulation of these key RAS pathway members can be beneficial in both instances. However, it's difficult to say how beneficial are the ACE inhibitors (ACEI)/ Angiotensin II type-1 receptor blockers (ARBs) during COVID-19. As a result, much more research is needed to better understand the relationship between the RAS and SARS-CoV-2 infection.

Post-inflammatory polyps burden as a prognostic marker of disease-outcome in patients with inflammatory bowel disease

INTRODUCTION AND AIM

Post-inflammatory polyps (PIPs) are considered as indicators of previous episodes of severe inflammation and mucosal ulceration. Inflammatory bowel disease (IBD), namely Crohn's disease (CD) and ulcerative colitis (UC), exhibit a perpetuating, relapsing, and remitting pattern and PIPs is a frequent sequela of chronicity. The aim of this study was to determine whether a high PIPs burden is associated with a more severe disease course in patients with IBD.

METHODS

This was a multinational, multicentre, retrospective study. IBD patients previously diagnosed with PIPs were retrieved from the endoscopic database of each centre. PIPs burden was evaluated and associated with demographic and clinical data as well as factors indicating a more unfavorable disease course.

RESULTS

A total of 504 IBD patients with PIPs were recruited (male: 61.9%). The mean age at IBD diagnosis was 36.9 (±16.8) years. Most patients (74.8%) were diagnosed with UC. A high PIPs burden was present in 53.4% of patients. On multivariable Cox regression analysis, high PIPs burden was independently associated with treatment escalation (HR 1.35, 95% CI 1.04-1.75; P=0.024), hospitalization (HR 1.90; 95% CI 1.24 - 2.90; P=0.003), need for surgery (HR 2.28; 95% CI 1.17-4.44, P=0.02) and younger age at diagnosis (HR 0.99, 95% CI 0.98-0,99; p=0.003).

CONCLUSION

PIPs burden was associated with a more severe outcome. Future prospective studies should focus on the characterisation of PIPs burden as to further risk stratify this patient cohort.

Biology of cancer; from cellular and molecular mechanisms to developmental processes and adaptation

Cancer research has been largely focused on the cellular and molecular levels of investigation. Recent data show that not only the cell but also the extracellular matrix plays a major role in the progression of malignancy. In this way, the cells and the extracellular matrix create a specific local microenvironment that supports malignant development. At the same time, cancer implies a systemic evolution which is closely related to developmental processes and adaptation. Consequently, there is currently a real gap between the local investigation of cancer at the microenvironmental level, and the pathophysiological approach to cancer as a systemic disease. In fact, the cells and the matrix are not only complementary structures but also interdependent components that act synergistically. Such relationships lead to cell-matrix integration, a supracellular form of biological organization that supports tissue development. The emergence of this supracellular level of organization, as a structure, leads to the emergence of the supracellular control of proliferation, as a supracellular function. In humans, proliferation is generally involved in developmental processes and adaptation. These processes suppose a specific configuration at the systemic level, which generates high-order guidance for local supracellular control of proliferation. In conclusion, the supracellular control of proliferation act as an interface between the downstream level of cell division and differentiation, and upstream level of developmental processes and adaptation. Understanding these processes and their disorders is useful not only to complete the big picture of malignancy as a systemic disease, but also to open new treatment perspectives in the form of etiopathogenic (supracellular or informational) therapies.

Obstructive Giant Inflammatory Polyposis as a First Manifestation of Crohn's Disease: A Case Report

Colonic inflammatory polyps (pseudopolyps) are common feature of inflammatory bowel diseases. They usually do not grow excessively, rarely reaching more than 15 mm in size, at which point they are termed giant inflammatory polyps. Clinical presentation of these polyps can vary greatly, ranging from being completely asymptomatic, usually detected incidentally, to abdominal cramps, rectal bleeding or intestinal obstruction. More importantly, giant inflammatory polyps can be easily mistaken for colonic malignancy, although without having malignant potential themselves. These polyps rarely regress with successful medical treatment of inflammatory bowel diseases and often require surgical treatment. We present an unusual case of giant inflammatory polyps which was the first presentation of inflammatory bowel disease. It was initially mistaken for colonic malignancy with intestinal obstruction, which led to surgical treatment.

Patients with inflammatory bowel disease and post-inflammatory polyps have an increased risk of colorectal neoplasia: A meta-analysis

BACKGROUND

Longstanding intestinal inflammation increases the risk of colorectal neoplasia in patients with inflammatory bowel disease (IBD). Accurately predicting the risk of colorectal neoplasia in the early stage is still challenging. Therefore, identifying visible warning markers of colorectal neoplasia in IBD patients is the focus of the current research. Post-inflammatory polyps (PIPs) are visible markers of severe inflammation under endoscopy. To date, there is controversy regarding the necessity of strengthened surveillance strategies for IBD patients with PIPs.

AIM

To determine whether IBD patients with PIPs carryan increased risk of colorectal neoplasia.

METHODS

Researchers searched the following databases up to July 31, 2021: MEDLINE (PubMed), MEDLINE (Ovid), EMBASE, Cochrane Library, China National Knowledge Infrastructure, Wan-Fang Data, China Science and Technology Journal Database and Chinese BioMedical Literature Database. Cohort and case-control studies that compared the risk of colorectal neoplasia between IBD patients with or without PIPs and published in English or Chinese were included. Methodological quality was assessed using the Risk of Bias in Nonrandomized Studies-of Interventions assessment tool. The outcomes of interest were the rates of various grades of colorectal neoplasia. The pooled risk ratio (RR) and 95% confidence interval (95%CI) were calculated using the random-effects model. Begg’s test and Egger’s test were used to calculate the publication bias. Sensitivity and subgroup analyses were performed to verify the robustness of the results. The Grading of Recommendations, Assessment, Development and Evaluation approach was used to assess the overall quality of evidence supporting the outcomes of interest.

RESULTS

Nine studies involving 5424 IBD patients (1944 with PIPs vs 3480 without PIPs) were included. The overall bias in each included study ranged from moderate to serious. Compared with nonconcurrent PIPs, patients with PIPs had a higher risk of colorectal neoplasia (RR = 1.74, 95%CI: 1.35-2.24, P < 0.001, I² = 81.4%; aHR = 1.31, 95%CI: 1.01-1.70, P = 0.04, I² = 26.2%; aOR = 2.62, 95%CI: 1.77-3.88, P < 0.001, I² = 0%), advanced colorectal neoplasia (RR = 2.07, 95%CI: 1.49-2.87, P < 0.001, I² = 77.4%; aHR = 1.63, 95%CI: 1.05-2.53, P = 0.03, I² = 10.1%) and colorectal cancer (RR = 1.93, 95%CI: 1.32-2.82, P = 0.001, I² = 83.0%). Publication bias was not observed in Begg’s test or Egger’s test. Sensitivity and subgroup analyses showed that the results are robust. The overall quality of evidence was assessed as moderate to low.

CONCLUSION

IBD patients with PIPs may have an increased incidence of colorectal neoplasia.

Increased risk of colorectal neoplasia in inflammatory bowel disease patients with post-inflammatory polyps: A systematic review and meta-analysis

BACKGROUND

Inflammatory bowel disease (IBD) patients with post-inflammatory polyps (PIPs) may carry an increased risk of colorectal neoplasia (CRN) including dysplasia and cancer. Current guidelines recommend active colonoscopy follow-up for these patients. However, the evidence for guidelines is still poor. In addition, some recent high-quality reports present a different view, which challenges the current guidelines. We hypothesize that IBD patients with PIPs are at increased risk of CRN.

AIM

To evaluate the risk of CRN in IBD patients with and without PIPs.

METHODS

A systematic search of PubMed, Embase, Cochrane Library, and Web of Science was performed to identify studies that compared the risk of CRN in IBD patients with and without PIPs. In addition, we screened the reference lists and citation indices of the included studies. Quality assessment was performed using the Newcastle-Ottawa Scale. Pooled odds ratio (OR) was calculated using the random-effects model to explore the final pooled effect size of the included studies and determine whether PIPs increase the risk of CRN. Sensitivity analysis, subgroup analysis, and assessment of publication bias were performed to examine the sources of heterogeneity.

RESULTS

Twelve studies with 5819 IBD patients, including 1281 (22.01%) with PIPs, were considered eligible for this meta-analysis. We found that IBD patients with PIPs were at an increased risk of CRN as compared to those without PIPs [OR 2.01; 95% confidence interval (CI): 1.43-2.83]. The results were similar when colorectal cancer was used as the study endpoint (OR 2.57; 95%CI: 1.69-3.91). Furthermore, the risk of CRN was still increased (OR 1.80; 95%CI: 1.12-2.91) when restricted to ulcerative colitis patients. Heterogeneity was high among the included studies (I² = 75%). Subgroup analysis revealed that the high heterogeneity was due to the study design. Sensitivity analysis showed that the main statistical outcomes did not essentially change after excluding any one of the included studies. No significant publication bias was found in the funnel plots.

CONCLUSION

IBD patients with PIPs have an increased risk of CRN as compared with those without PIPs, which support the current guidelines. However, a high-quality randomized controlled trial is warranted.

LARGE INTESTINE OBSTRUCTION CAUSED BY PSEUDOPOLYPOSIS IN THE COURSE OF ULCERATIVE COLITIS - A CASE REPORT

Ulcerative colitis is an inflammatory bowel disease. Opposite to Crohn's disease, it affects only the mucosa and submucosa of the large intestine. The disease can have episodes of flares and remissions. Endoscopy studies often disclose pseudopolyps, which are perceived as non-neoplastic and usually do not require removal. Rarely pseudopolyps can become big or even gigantic, leading to abdominal pain, bowel movement dysfunction, or even bowel obstruction. We present a case of a 37-year-old male patient with ulcerative colitis who was operated on because of a gigantic pseudopolyp causing bowel obstruction.

[Position paper on endoscopic reporting in IBD]

The complete and reliable documentation of endoscopic findings make up the crucial foundation for the treatment of patients with inflammatory bowel diseases such as Crohn´s disease and ulcerative colitis. These findings are, on the one hand, a prerequisite for therapeutic decisions and, on the other hand, important as a tool for assessing the response to ongoing treatments. Endoscopic reports should, therefore, be recorded according to standardized criteria to ensure that the findings of different endoscopists can be adequately compared and that changes in the course of the disease can be traced back. In consideration of these necessities, fifteen members of the Imaging Working Group of the German Kompetenznetz Darmerkrankungen have created a position paper proposing a structure and specifications for the documentation of endoscopic exams. In addition to the formal report structure, the recommendations address a large number of attributes of acute and chronic inflammatory alterations as well as endoscopically detectable complications, which are explained in detail and illustrated using exemplary images. In addition, more frequently used endoscopic activity indices are presented and their use in everyday clinical practice is discussed.

Clinicopathologic Characteristics and Neoplasia Risk of Colorectal Inflammatory Polyposis in Inflammatory Bowel Disease

CONTEXT.—

Inflammatory polyps (IPs) in inflammatory bowel disease may have been associated in the past with increased neoplasia risk. Additionally, colonic mucosa in filiform polyposis and giant inflammatory polyposis may be difficult to visualize during endoscopic surveillance, perhaps contributing to early colectomy in these patients.

OBJECTIVE.—

To examine the clinicopathologic characteristics and significance of IPs and inflammatory polyposis in inflammatory bowel disease.

DESIGN.—

We identified 336 resections from inflammatory bowel disease patients (212 [63.1%] male; mean age, 40.3 years; 175 [52.1%] with ulcerative colitis), including 78 with rare/few (<10) IPs, 141 with multiple (≥10) IPs, and 117 with inflammatory polyposis (including 30 with filiform polyposis/giant inflammatory polyposis) and compared them with 100 controls without IPs along various parameters, including overall and occult (unexpected) dysplasia.

RESULTS.—

There was no increased neoplasia in resections with IPs compared with controls, given similar age, disease duration, degree of inflammation, anatomical extent of colitis, prevalence of primary sclerosing cholangitis, and tissue sampling. Increasing numbers of IPs and inflammatory polyposis were significantly associated in multivariate analysis with ulcerative and indeterminate colitis (P = .003) and shorter disease duration (P = .01), but also, and independently, with lower rates of dysplasia overall, including all grades (P = .001) and advanced neoplasia (P = .04). There were no instances of occult dysplasia (any grade) among inflammatory polyposis cases.

CONCLUSIONS.—

These findings support the conclusion that the presence of IPs per se, and inflammatory polyposis in particular (including filiform polyposis and giant inflammatory polyposis), should not be considered an independent risk factor for the development of neoplasia in inflammatory bowel disease patients, outside the context of disease duration and inflammatory burden.

Colonoscopic Diagnosis of Postoperative Gastrointestinal Bleeding in Patients With Hirschsprung's Disease

Aim: Postoperative lower gastrointestinal bleeding in children with Hirschsprung's Disease (HSCR) is a non-specific symptom, which may be caused by various etiologies. Our current study aims to utilize colonoscopy to diagnose the causes of postoperative hematochezia and to analyze its feasibility, accuracy, and safety. Methods: Twenty-four patients with HSCR with postoperative lower gastrointestinal bleeding or occult blood in the stool were enrolled in this study. The postoperative onset duration, age at examination, accompanied anomalies were recorded. After bowel preparation, all patients underwent colonoscopy. According to visual findings, mucosal biopsy was performed, followed by pathological diagnosis. Further treatment was determined according to the visual findings and pathological diagnosis. All patients were followed up for 6 months including therapeutic outcomes and recurrence of symptoms. Results: The mean onset duration was (221.3 ± 216.8) days postoperatively (ranging from 25 to 768 days). The mean age at examination was (41.0 ± 29.4) months. There was no significant difference in the onset days among each group (all, p > 0.05). Based on visual and pathological findings, there were 11 cases of HSCR associated enterocolitis (HAEC), 4 cases of anastomotic leakage, 7 cases of anastomotic inflammation, 1 case of juvenile polyp, and 1 case of inflammatory pseudopolyp. Intraluminal saline irrigation, thrombin treatment or colorectal polyp electrocision was performed according to intraoperative diagnosis. Patients with HEAC and anastomotic inflammation underwent antibiotics therapy and colorectal irrigation. Patients with leakage underwent reoperation. The highest incidence of accompanied symptoms of diarrhea existed in HEAC group (p = 0.02) and fever in leakage group (p = 0.02), respectively. No perforation or aggravated bleeding occurs in any patients. All patients gained uneventful recovery during follow-up period. Conclusions: Colonoscopy is a safe, accurate and timely examination for HSCR patients with postoperative lower gastrointestinal bleeding. The visual findings and biopsy may provide accurate diagnosis and guide treatment for this subset of patients.

No Increased Risk of Colorectal Neoplasia in Patients With Inflammatory Bowel Disease and Postinflammatory Polyps

BACKGROUND

Patients with inflammatory bowel disease (IBD) who have postinflammatory polyps (PIPs) may have an increased risk of developing colorectal neoplasia. Current guidelines recommend an intensified surveillance strategy in these patients, although the evidence for this recommendation is conflicting. The aim of our study was to assess whether IBD patients with PIPs are at increased risk of colorectal neoplasia.

METHODS

We established a retrospective cohort in a tertiary IBD center with IBD patients undergoing colorectal cancer (CRC) surveillance in the current era. We compared cumulative incidences of colorectal neoplasia since IBD diagnosis between patients with and without PIPs and corrected for confounders. Second, we compared the risk of receiving a colectomy.

RESULTS

In our cohort with >22 years of median follow-up, 154 of 519 patients had PIPs. PIPs were associated with extensive disease (odds ratio [OR], 2.76; 95% confidence interval [CI], 1.61-4.42; P < 0.001) and with more severe inflammation at colonoscopy (OR, 3.54; 95% CI, 2.28-5.50; P < 0.001). After correction for confounders, the presence of PIPs was not associated with development of colorectal neoplasia (hazard ratio [HR], 1.28; 95% CI, 0.85-1.93; P = 0.24) or with development of advanced neoplasia (HR, 1.38; 95% CI, 0.52-3.68; P = 0.52). There was a higher risk of colectomy in patients with PIPs (HR, 3.41; 95% CI, 1.55-7.54; P = 0.002).

CONCLUSION

In this cohort, PIPs were associated with disease extent, inflammation, and higher rates of colectomy. However, the presence of PIPs was not associated with the development of neoplasia. These findings suggest that patients with PIPs may not need an intensified surveillance strategy.

Colonoscopic techniques in polyp detection: An Egyptian study

INTRODUCTION AND AIMS

The polyp detection rate (PDR) is defined as the percentage of colonoscopies in which one or more polyps are detected, and has been shown to be highly correlated with the adenoma detection rate. The aim of the present study was to evaluate the PDR at the Endoscopy Unit of the Kasr Al-Ainy Hospital, Cairo University, Egypt, through the i-SCAN, Endocuff, and underwater colonoscopy techniques.

MATERIALS AND METHODS

The study was conducted on 100 Egyptian subjects over 50 years of age. Their polyp detection rate was measured through 4 different colonoscopic techniques. An equal number of patients were divided into 4 groups: i-SCAN, Endocuff, underwater colonoscopy, and controls. The control group was examined using standard white light colonoscopy. The colonoscopy evaluation included the type of agent utilized for bowel preparation, preparation grade, and colonoscopy withdrawal time.

RESULTS

The general PDR was 48%. The i-SCAN technique had the highest rate (56%), followed by the underwater (52%) and the Endocuff (48%) techniques.

CONCLUSION

The i-SCAN and underwater colonoscopy techniques produced higher PDR than the Endocuff-assisted and standard techniques, but with no statistical significance.

Giant Inflammatory Polyps in Diverticular Disease Mimicking a Colonic Mass: A Potential Malignant Masquerader

BACKGROUND Inflammatory pseudopolyps (IPPs) are a common manifestation in inflammatory bowel disease (IBD) with more cases reported with ulcerative colitis than Crohn's disease. IPPs can grow to form large polyps which are called giant inflammatory polyps (GIPs). These polyps may cause an obstruction and form a mass-like lesion and surgical resection may be warranted. CASE REPORT A 65-year-old male without a previous history of IBD presented with abdominal discomfort, poor appetite, constipation, weight loss, and hematochezia. Due to the high suspicion of malignancy, a computed tomography (CT) scan was performed and showed a fixed lesion in the mid sigmoid colon highly concerning for a primary colon carcinoma, with scattered diverticula, and associated with elevated carcinoembryonic antigen (CEA). Colonoscopy was done but the scope could not be passed due to obstruction. Sigmoidectomy was performed which showed a huge noninvasive lesion, which looked like pseudopolypoid serpiginous mass as giant inflammatory polyp, with scattered diverticula. On microscopic examination, pathology showed a villous polyp with numerous inflammatory cells, without any dysplasia or carcinoma. CONCLUSIONS GIPs are rarely reported without a history of IBD. Diagnosis of GIPs can be very challenging, and surgery is sometimes indicated for definitive diagnosis.

Limitations of the determination of faecal calprotectin in patients with ulcerative colitis and inflammatory polyps

INTRODUCTION

Faecal calprotectin is a useful technique for detecting activity in patients with ulcerative colitis. However, there may be high levels due to factors other than the activity of ulcerative colitis. Our aim was to analyse possible false positive results of calprotectin for the activity of ulcerative colitis owing to the presence of inflammatory polyps.

PATIENTS AND METHODS

Retrospective, observational, descriptive study. Data was collected from patients monitored for 2 years in whom a colonoscopy had been requested within 3 months after detecting high calprotectin values (>150μg/g) and before modifying the treatment.

RESULTS

We reviewed 39 patients and in 5 of them, with previous diagnosis of extensive ulcerative colitis, inflammatory polyps were detected. Three patients were on treatment with mesalazine, one with azathioprine and other with infliximab. All of them were asymptomatic and the endoscopy did not show macroscopic activity (endoscopic Mayo score=0) or histological activity. The median values of calprotectin were 422μg/g (IQR: 298-2,408) and they remained elevated in a second measurement. In 4 of the patients the inflammatory polyps were multiple and small in size. The other patient had a polyp measuring 4cm.

DISCUSSION

In clinical practice we can find high faecal calprotectin levels not due to the presence of ulcerative colitis activity, but due to other lesions such as inflammatory polyps. This fact must be taken into account before carrying out relevant changes such as step-up therapy to immunosuppressive drugs or biological drugs in patients with confirmed high calprotectin levels.

Does the Presence of Giant Pseudopolyps in a Patient with Newly Diagnosed Inflammatory Bowel Disease Increase the Risk of Major Thrombotic Events?

Giant inflammatory polyp and thromboembolism are uncommon complications in inflammatory bowel disease (IBD) patients. Colon mucosal inflammation is possibly the main mechanism of pathogenesis for these two complications. IBD has long been associated with hypercoagulability and thromboembolism. In fact, thromboembolism has been noted in 0.7% to 7.7% of IBD patients, with the deep veins of the legs and the pulmonary veins accounting for 90% of the cases. The proposed mechanism of this hypercoagulability involves the promotion of hemostasis that results from the inflammatory process underlying the IBD, as well as the loss of proteins, including antithrombotic factors, resulting from the inflamed bowel and increased permeability of the colonic mucosa. This process may be exacerbated by the presence of giant inflammatory polyps, which are defined as polyps in the setting of IBD with dimensions greater than 1.5 cm. The presence of these polyps leads to an increase in inflamed colonic surface area, which can accelerate the rate of protein loss, leading to an increased incidence of thrombosis. Here, we report the case of a 21-year-old female with inferior vena cava and left renal vein thromboses secondary to a newly diagnosed IBD and the presence of severe giant inflammatory polyposis. These thromboses were detected incidentally in this patient after 1 week of hospitalization. She had presented with hypoalbuminemia and elevated inflammatory markers, which raised the suspicion for possible giant inflammatory polyposis as a potential risk for her major thromboembolic events. More studies are required to explore this plausible correlation further.

Has the time been reached for pseudopolyps to be re-enrolled in endoscopic inflammatory bowel disease scores?

Patients with inflammatory bowel diseases (IBD) represent heterogeneous groups with different characteristics and different clinical course. A great deal of effort is made to discover proxies for more severe disease needing more intense treatment and early intervention to gain the maximum therapeutic benefit. Endoscopy remains an invaluable method in assessment of patients with IBD. Pseudopolyps are often encountered during endoscopy and, although they are a well described entity, their presence is of unclear importance. In one of our recent studies and in conjunction with one study with a large cohort of patients with IBD and pseudopolyps, patients with pseudopolyps were found to face a higher inflammatory burden in terms of receiving more intense biological treatment. This letter comes as a comment and proposition regarding the concept of re-evaluation of pseudopolyps as a promising marker in IBD scores.

Upper Gastrointestinal Crohn's Disease: Literature Review and Case Presentation

Upper gastrointestinal tract predominant Crohn's Disease (CD) remains an elusive clinical entity, manifesting limited or vague symptomatology, eluding clinical suspicion, and delaying subsequent diagnostic evaluation. As a result, it has not been widely described and there is a lack of clear recommendations for diagnosis or management. Standard IBD evaluation including serologic testing, imaging, and endoscopy may initially not be fruitful. Furthermore, endoscopic evaluation may be grossly normal in patients without long standing-disease. We describe an 18-year-old male who presented with only unexplained, persistent iron-deficiency anemia. Extensive outpatient testing including multiple endoscopic evaluations with standard biopsies was unfruitful. Ultimately, a positive fecal calprotectin prompted enteroscopy with endoscopic mucosal resection (EMR) in an effort to obtain a larger, deeper tissue specimen. Grossly cobblestoned mucosa along with histopathology revealing focal crypt abscesses, chronic inflammation in the lamina propria, and superficial foveolar epithelial regenerative changes were consistent with CD. This patient's case illustrates the need for a high degree of suspicion for CD in patients with unexplained or persistent iron deficiency anemias. Persistent investigation yielded an elevation in fecal calprotectin suggesting underlying gastrointestinal inflammation and prompted advanced endoscopic evaluation with EMR. Waxing and waning tissue findings are characteristic of CD and pose a unique challenge in patients with upper gastrointestinal predominant pathology. As such, diligent workup including laboratory evaluation, imaging, and serial endoscopy is critical to establish pathology and dictate subsequent management in IBD, especially upper gastrointestinal tract predominant CD.

No Association Between Pseudopolyps and Colorectal Neoplasia in Patients With Inflammatory Bowel Diseases

BACKGROUND & AIMS

Patients with inflammatory bowel diseases who have postinflammatory polyps (PIPs) have an increased risk of colorectal neoplasia (CRN). European guidelines propose that patients with PIPs receive more frequent surveillance colonoscopies, despite limited evidence of this increased risk. We aimed to define the risk of CRN and colectomy in patients with inflammatory bowel diseases and PIPs.

METHODS

We conducted a multicenter retrospective cohort study of patients with inflammatory bowel diseases who underwent colonoscopic surveillance for CRN, from January 1997 through January 2017, at 5 academic hospitals and 2 large nonacademic hospitals in New York or the Netherlands. Eligible patients had confirmed colonic disease with duration of at least 8 years (or any duration, if they also had primary sclerosing cholangitis) and no history of advanced CRN (high-grade dysplasia or colorectal cancer) or colectomy. The primary outcome was occurrence of advanced CRN according to PIP status; secondary outcomes were occurrence of CRN (inclusive of low-grade dysplasia) and colectomy.

RESULTS

Of 1582 eligible patients, 462 (29.2%) had PIPs. PIPs were associated with more severe inflammation (adjusted odds ratio 1.32; 95% confidence interval [CI] 1.13-1.55), greater disease extent (adjusted odds ratio 1.92; 95% CI 1.34-2.74), and lower likelihood of primary sclerosing cholangitis (adjusted odds ratio 0.38; 95% CI 0.26-0.55). During a median follow-up period of 4.8 years, the time until development of advanced CRN did not differ significantly between patients with and those without PIPs. PIPs did not independently increase the risk of advanced CRN (adjusted hazard ratio 1.17; 95% CI 0.59-2.31). The colectomy rate was significantly higher in patients with PIPs (P = .01).

CONCLUSIONS

In a retrospective analysis of data from 2 large independent surveillance cohorts, PIPs were associated with greater severity and extent of colon inflammation and higher rates of colectomy, but were not associated with development of any degree of CRN. Therefore, intervals for surveillance should not be shortened based solely on the presence of PIPs.

Complete Regression of Giant Inflammatory Polyp after Treatment with Adalimumab

Giant inflammatory polyps (GIPs) are a rare complication of IBD resulting from chronic regenerative and healing processes leading to a polypoid formation on inflamed mucosa. We reported a case of GIP in a patient with long standing left-sided ulcerative colitis (UC); a well circumscribed sessile GIP was found during a colonoscopy for colorectal cancer screening on a normal colonic mucosa in the cecum. After a severe flare of the left-sided colitis and due to partial response to steroids patient was treated with adalimumab; new colonoscopy after 6 months shows complete disappearance of the GIP previously described. It is the first case report of GIP in normal macroscopic mucosa with complete disappearance after biologic treatment.

ACG Clinical Guideline: Ulcerative Colitis in Adults

Ulcerative colitis (UC) is an idiopathic inflammatory disorder. These guidelines indicate the preferred approach to the management of adults with UC and represent the official practice recommendations of the American College of Gastroenterology. The scientific evidence for these guidelines was evaluated using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) process. In instances where the evidence was not appropriate for GRADE, but there was consensus of significant clinical merit, "key concept" statements were developed using expert consensus. These guidelines are meant to be broadly applicable and should be viewed as the preferred, but not only, approach to clinical scenarios.

Differentiation between intestinal Behçet’s disease and Crohn’sdisease based on endoscopy

Background/aim

Differentiating intestinal Behçet’s disease (BD) from Crohn’s disease (CD) is highly challenging, as they often mimic each other in terms of clinical manifestations. Endoscopy is an important modality for distinguishing bowel lesions. The study was designed to identify clinical manifestations that are easily confused and to evaluate the efficacy of endoscopy for distinguishing intestinal BD from CD by several overlapping signs.

Materials and methods

The data from 111 patients with intestinal BD and 81 patients with CD were retrospectively analyzed. Logistic regression was applied to establish a prediction model based on endoscopic findings for the differential diagnosis. The diagnostic efficacy of endoscopy was verified using the area under the receiver operating characteristic (ROC) curve.

Results

Among intestinal BD patients mucocutaneous lesions were the leading clinical manifestations. Gastrointestinal symptoms were common in CD but were rare in intestinal BD (P < 0.001). CD patients with moderate-to-severe activity were more common than intestinal BD patients presenting with equivalent activity (P < 0.05). Independent factors that distinguished intestinal BD from CD were solitary ulcer in the ileocecal area (P < 0.001), perianal abscess (P = 0.049), single segment (P < 0.001), round intestinal ulcer (P = 0.013), intestinal obstruction (P = 0.035), and fistula (P < 0.001). The scores ranged from –2 to 3. The area under the ROC curve was 0.874 (95% CI: 0.823–0.926) (P < 0.001). With a score of 1.5 as the diagnostic cutoff value, the sensitivity and specificity were 76.3% and 80.6%, respectively.

Conclusion

Mucosal injuries were rarer in patients with intestinal BD than in those with CD. The differentiation model combining several endoscopy features appeared to be reliable for distinguishing between intestinal BD and CD.

Presence of pseudopolyps in ulcerative colitis is associated with a higher risk for treatment escalation

Background

Pseudopolyps in ulcerative colitis (UC) are considered as indicators of previous episodes of severe inflammation and ulceration of the mucosa. The aim of the study was to investigate the long-term outcomes of patients treated for UC, with or without pseudopolyps.

Methods

This was a retrospective single-center study. Consecutive patients with UC and available endoscopic data from 2000 until 2016 were eligible for the study and were followed until June 2017. Patients with incomplete medical/endoscopic charts or interrupted follow up were excluded from the study. Primary outcomes included time to treatment escalation, treatment escalation to biological agents or surgery, and UC-related hospitalization.

Results

Eighty-three UC patients were included in the study, of whom 25 (30%) had pseudopolyps. The median duration of follow up was 2.8 years (interquartile range: 1.1-4.9). Multiple Cox regression analysis identified the presence of pseudopolyps as the only variable independently associated with treatment escalation (hazard ratio [HR] 2.3, 95% confidence interval [CI] 1.2-4.3; P=0.014) and escalation to biological agents or surgery (HR 6.3, 95%CI 1.9-20.7; P=0.002).

Conclusion

This retrospective single-center study provides the first preliminary evidence that patients with UC and pseudopolyps may represent a subpopulation with a higher inflammatory burden and a greater need for treatment escalation, including to biological agents or surgery. Large, prospective multicenter studies are certainly warranted to confirm these findings.

Neoterminal Ileal Polyposis and Ulceration after Restorative Proctocolectomy with a Current Review of the Literature

After ileal pouch anal anastomosis, one of the frequently encountered complications is polyposis of the pouch. We describe a case of proximal neoterminal ileal polyposis associated with deep ulceration suggestive of Crohn's disease and review the available literature. A 36-year-old male presented with resistant pouchitis 11 years after surgery for ulcerative colitis. With all-negative initial workup, pouchoscopy showed multiple deep ulcers in the proximal ileum with some polyps. Biopsy of polyps showed inflammatory polyps with negative immunohistological staining for IgG pouchitis. With no treatable etiology for pouchitis and the presence of inflammatory polyps, there are no guidelines for surveillance of this condition. Definitive diagnosis is challenging and there is no consensus or recommended guidelines on the management.